- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,663.82 / $3,663.82 / $19,200.00
| Facility | | $3,663.82 | $3,663.82 | $19,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,663.82 / $4,601.09 / $4,601.09
| Professional | | $3,663.82 | $4,601.09 | $4,601.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,960.13 / $17,129.73 / $21,200.16
| Professional | | $16,960.13 | $17,129.73 | $21,200.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,663.82 / $16,809.59 / $26,288.00
| Facility | | $3,663.82 | $16,809.59 | $26,288.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,680.00 / $19,200.00 / $21,120.00
| Professional | | $7,680.00 | $19,200.00 | $21,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,680.00 / $19,200.00 / $21,504.00
| Professional | | $7,680.00 | $19,200.00 | $21,504.00 |